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How a Mass. health system boosted patient safety reporting by 500%
It wasn't just IT that helped Emerson Health boost patient safety reporting by 500%. The health system also invested in building a just culture around patient safety.
At Massachusetts-based Emerson Health, patient safety reporting isn't just about having a tool to flag an event; it's about staff having the psychological safety to use it, too, according to Christi Barney, Emerson's vice president of quality and patient safety and chief health equity officer.
To be sure, digital patient safety reporting systems are important to healthcare organizations. These are the tools employees can use to flag when there's been a patient safety event and, depending on the technology, see how it is resolved.
But according to Barney, patient safety reporting doesn't suffer because health systems don't have the right IT setup. It's because the health system doesn't have a just culture of patient safety in place that gives staff the psychological safety to speak up about incidents without fear of punitive action.
Emerson knows something about fostering psychological safety in staff, spending most of its post-pandemic years focusing on building a just culture around patient safety and ultimately achieving a 500% increase in patient safety reporting.
"We really wanted to use safety reporting as one mechanism to do high-reliability culture work," Barney said in an interview. "We wanted to make sure that all of the frontline staff -- everyone from the housekeepers to the physicians -- had access to our safety reporting platform and that they would have assurance that if they took the time and energy to put in a safety report, something was going to happen from it."
By implementing its patient safety reporting system with an emphasis on a just culture, Emerson sought to reframe employees' roles in improving clinical quality.
Focusing on a just culture for patient safety
Healthcare's patient safety challenges are well documented, starting in 2000 with the Institute of Medicine's seminal report, To Err is Human.
The industry has made significant strides in reducing preventable patient harm since the report's publication, but challenges remain. In 2023, researchers reported that patient safety events occur in about a quarter of inpatient hospitalizations.
And those are just the safety events that organizations know about. In 2025, a report from the Office of Inspector General showed that around half of patient safety events go unreported.
It doesn't take a lot to understand why.
Hospital staff are unlikely to report adverse patient safety events if they think they will get in serious trouble, especially if that event was a "near-miss" event in which no patient harm actually occurred.
While adverse patient safety events do warrant corrective action, experts agree that most corrective action should not be punitive.
"We look at human factors, but a lot of that comes down to this concern about whether or not we've equipped the humans well," Barney explained. "We may have had gaps in our training, or we may not have built a system around people that supports them doing their very best work."
A patient safety event is not typically a personal failure of a staff member or team, but rather a system failure.
Barney's team at Emerson has done significant work to build a just culture in medicine. Just cultures balance personal accountability with systems accountability when something goes wrong, making patient safety case reviews and corrective actions fairer.
This builds psychological safety among staff members, making them feel more comfortable submitting a patient safety event in an organization's reporting system.
IT gives visibility into adverse event resolution
But building a just culture is half the battle, Barney pointed out. If people are going to take the time to submit a patient safety event, they want to know how it's being addressed. That requires having the best technology in place and a team willing to conduct corrective action reviews.
"Over the years, we've struggled with people saying a barrier to reporting is that it feels like it goes into a black hole, and they never know what's going on," Barney noted. "We wanted to address that."
Emerson uses RLDatix to collect patient safety event reports. According to Barney, the system doesn't just collect reports, it also lets individuals involved in the event see how the case review is progressing, who is involved and, ultimately, how it's been resolved.
Importantly, technology alone doesn't solve a problem. Without a dedicated team focused on quality and patient safety, Emerson would not be able to do thorough follow-ups on patient safety flags.
Addressing adverse patient safety events
Having a multi-step system for reviewing adverse patient safety events has been integral for building trust among staff members, Barney explained. When people know the health system will handle a patient safety event, they are more likely to speak up.
The review process begins with Barney's daily review of patient safety events submitted to Emerson's system.
Take, for example, the issue of a patient getting their medicine late.
This type of event will usually set off a more thorough collaborative case review with other relevant parties, such as the medication safety pharmacist, the staff on the floor, the nurse leadership on the floor and anyone else who might have a relevant perspective.
Together, these individuals think through the systems that affect medications, including the medication record in the EHR, the competing priorities that providers managed that day and even the training providers receive in administering this type of medication.
From there, Barney and her team think through Emerson's opportunities to improve, such as setting up more staff training or considering a more intuitive EHR workflow or staffing system.
Importantly, Barney and her team consider how these events affected everyone involved. While most organizations have a plan for disclosing medical errors and adverse patient safety events to patients and families, Barney said it's also important to think of the staff members involved.
Certainly, giving a glimpse into the entire review process can be cathartic for clinicians, she said, but Emerson also prioritizes giving staff an opportunity to debrief.
"It can't be underestimated how much of the work you're doing in quality and safety is also about the emotional health and safety of the team," Barney said. "Not only how did we take care of the patient and their family, but what about us? What about the team? Did they take time to debrief?"
Approaching patient safety reporting holistically has yielded tremendous results for Emerson, Barney said. The health system has seen a 500% increase in patient safety event reporting, while also boosting its near-miss reporting from 18% to 58%.
Those gains have been made possible by examining the systems at play and not punishing the humans involved, Barney added. Doing so creates processes that empower individuals to do their best work.
"The people who choose to work in healthcare are doing this because they want to make a difference and they want to do the right thing," Barney concluded. "Usually, when something doesn't go to plan, it has something to do with either competing priorities or a system design that doesn't let people do the thing that they intended to do."
Sara Heath has reported news related to patient engagement and health equity since 2015.
